Initiative helps health plan beat national averages
Self-management, physician incentives are part
A comprehensive asthma management program has paid off for Care Choices HMO of Farmington Hills, MI. The health plan received the "best-in-class" designation in the National Committee Quality Assurance’s Quality Compass 2003 report in appropriate use of medications for people with asthma, ages 5-9, and was listed as No. 1 in Southeast Michigan and 10th in the nation in use of appropriate medication for people with asthma in all ages.
The comprehensive program includes self-management support for all members with asthma; case management and collaboration with practitioners on individual care for at-risk patients; and physician reminders and physician incentives that support appropriate asthma management.
"A number of factors contributed to Care Choices clinical performances, including outreach, education, and care management incentives. Since we began our programs for diabetes and asthma, we have seen an improvement of more than 10 percentage points in key quality-of-care measures. Committed and involved physicians are the key to attaining such results," says Gilbert Burgos, MD, MPH, chief medical officer of Care Choices.
For instance, for members ages 5-56 years with persistent asthma, 77.72% of Care Choices members were prescribed appropriate medications in the past year, compared with the national average of 67.93% and 67.72% for Care Choices in 2001.
Care Choices began its asthma program in 1999 after an analysis of utilization data and performance rates identified that as a priority area, says Linda Hayden RN, BSN, project manager in the medical affairs division for Care Choices.
Members are placed in the Care Choices Asthma Registry if they have four ambulatory visits for asthma in a 12-month period, fill a prescription for asthma medications four times, or have one inpatient or emergency department (ED) visit for asthma.
All members who meet the criteria get population-based information on asthma self-management, including direct mailings, newsletter and web site articles, and Internet links that address the components of appropriate asthma management.
Members who have utilized the ED or had an inpatient admission for asthma are referred to case management for evaluation, Hayden says.
Patients also may be enrolled in the program upon physician recommendations or if they call the plan’s toll-free health line and request it.
Care Choices utilization managers may recommend someone for case management if they don’t quite meet the criteria but need help managing their asthma, Hayden says.
The plan has works with a hospital-based utilization nurse and case manager who notify the Care Choices case managers when a member is hospitalized or treated in the ED for asthma.
"Coordinated care is an important issue, especially with emergency room visits and inpatient admissions," Hayden says.
The plan encourages patients to follow up with their primary care physician within a week of an ED visit or inpatient admission.
"It takes a team of people to develop and implement a comprehensive disease management program. The Care Choices team includes member benefits, nurses, physicians, pharmacy, marketing, community programs and linkages, and information system. A physician champion is very important to support and promote the program and ensure the physician and member educational information is clinically correct," Hayden says.
A key component of the asthma management program is a quality incentive program that rewards physicians financially when they work closely with their asthma patients to ensure that they are taking their medication properly.
Care Choices tracks medication usage in its members with asthma and sends a monthly "Quality Incentive Report" to primary care physicians identifying each of his or her patients who had one or more short-acting bronchodilator prescriptions filled in a six-month period.
The purpose of the report is to help the physician monitor the use of short-acting medication, identify patients who are at-risk, promote physician follow-up, and encourage the use of long-acting medications when appropriate, Hayden says.
The primary care physicians receive a financial incentive payment based on the number of patients who refilled a prescription for a short-acting bronchodilator fewer than three times in a six-month period.
"The quality incentive initiative helps us identify at-risk individuals, it helps promote follow up by the physicians, and it encourages the use of long-acting medication rather than short-term rescue medication," Hayden says.
When an at-risk member is referred to case management, the Care Choices case manager contacts the member’s primary care physician.
Then the case manager contacts the member, conducts an asthma survey, and begins working with the member to establish goals supported by an asthma action plan that includes using the appropriate medicines and the appropriate time and following up with the physician.
The asthma action plan is an individualized management guide that describes how to treat and control asthma, whether the member is experiencing symptoms or not. It may include asthma signs and symptoms, steps the patient should take when peak flow meter measures reach a certain level, medications, and a list of triggers.
The case managers and the members work together to develop mutual goals. Goals may be appropriate medication management or following up with physicians.
Other goals may be getting immunizations for flu or pneumonia or cutting out exposure to second-hand smoke.
"We are trying to provide a comprehensive means of addressing at-risk individuals. We try to tie them into other programs. For instance, we have a free stop-smoking program that has an excellent quit rate. If the member doesn’t smoke but is exposed to second-hand smoke, we raise that issue as well," Hayden says.
The program is tied in with other Care Choices programs, such as a program to increase adult immunizations for flu and pneumonia and a community-based asthma education program that provides face-to-face, one-on-one education such as instruction on using peak flow meters and when to use what medication.
The frequency of follow-up contacts is individualized based on the needs of the member.
"We assign our case managers by geographic area so there is a consistent message approach provided to physicians and to patients," Hayden says.
When the members meet their goals, they may not receive one-to-one contact from a case manager but they remain in the registry and receive the educational information at regular intervals.
"With asthma, some seasons are worse than others. It is a chronic disease, and we want to assure appropriate self-management," Hayden says.
Care Choices participates in the Michigan Quality Improvement initiative, a collaborative effort that develops consistent evidence-based clinical practice guidelines that all health plans send to physicians.
"It was a barrier for physicians to receive a number of different guidelines from the different health plans. We have worked to develop and implement one set of evidence-based guidelines for various conditions, including asthma," Hayden says.
When the plan sends out a mailing to members with asthma, it sends the same mailing to the physicians so they can be prepared for inquiries.
Physician office staff are included in the educational process.
"We have found out through experience how important it is for the physician’s office to be educated about chronic diseases. We provide asthma educational materials to the office staff and the nurses as well as the physicians," Hayden says.
The plan studies its data on an annual basis and looks for what works well and what doesn’t. "We do a barrier analysis to find out what is working well and used trends to try to improve," she says.
A comprehensive asthma management program has paid off for Care Choices HMO of Farmington Hills, MI.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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